Nursing Elites

1. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which clinical finding is most concerning?

• A. Serum glucose of 500 mg/dl
• B. Blood pressure of 140/90 mmHg
• C. Serum osmolarity of 320 mOsm/kg
• D. Serum pH of 7.30

Correct answer: C

Rationale: A serum osmolarity of 320 mOsm/kg is the most concerning finding in a client with hyperglycemic hyperosmolar syndrome (HHS). This level of osmolarity indicates severe dehydration and hyperosmolarity, putting the client at risk of complications like organ failure. Immediate intervention is crucial to address the dehydration and restore fluid balance. The other options, while important in the overall assessment of a client with HHS, do not directly indicate the severity of dehydration and hyperosmolarity seen with a high serum osmolarity level.

2. In caring for a client receiving the aminoglycoside antibiotic gentamicin, what diagnostic test should the nurse prioritize monitoring?

• A. Urinalysis
• B. Serum creatinine
• C. Serum osmolarity
• D. Liver enzymes

Correct answer: B

Rationale: The correct answer is B: Serum creatinine. Aminoglycosides, such as gentamicin, are known to cause nephrotoxicity, which can lead to kidney damage. Monitoring serum creatinine levels is crucial in assessing renal function and detecting any potential kidney problems early. Choices A, C, and D are incorrect because urinalysis primarily assesses urine composition, serum osmolarity measures the concentration of solutes in the blood, and liver enzymes are not directly impacted by aminoglycoside antibiotics like gentamicin.

3. A client with a postoperative wound that eviscerated yesterday has an elevated temperature. Which intervention is most important for the nurse to implement?

• A. Initiate contact isolation.
• B. Obtain a wound swab for culture and sensitivity.
• C. Assess temperature every 4 hours.
• D. Use alcohol-based solutions for hand hygiene.

Correct answer: B

Rationale: In this scenario, the most critical intervention is to obtain a wound swab for culture and sensitivity. This will help identify the causative organism present in the wound, enabling healthcare providers to prescribe the appropriate treatment. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case where infection is suspected. Assessing the temperature (Choice C) is important for monitoring the client's condition but does not address the underlying cause. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but does not directly address the client's specific condition of a postoperative wound with evisceration and elevated temperature.

4. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?

• A. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure
• B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness
• C. The additive effect of multiple medications has caused the blood pressure to drop too low.
• D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.

Correct answer: C

Rationale: When medications with a similar action are administered, an additive effect occurs that is the sum of the effects of each medication. In this case, several medications that all lower blood pressure, when administered together, resulted in hypotension.

5. Which nursing intervention is most important when caring for a client with myasthenia gravis?

• A. Encourage the client to rest frequently.
• B. Administer medication 30 minutes before meals.
• C. Maintain a patent airway.
• D. Monitor for signs of respiratory infection.

Correct answer: C

Rationale: Maintaining a patent airway is crucial for clients with myasthenia gravis because muscle weakness can affect the muscles responsible for breathing, potentially leading to respiratory compromise. Encouraging rest, administering medication, and monitoring for respiratory infections are important aspects of care but do not take precedence over ensuring a patent airway for adequate oxygenation.

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